Wednesday, 8 May 2013

ECG of the Week - 6th May 2013 - Interpretation

I don't have any clinical information on this case unfortunately but it looks like an interesting ECG :-)

  • Overall rate 60 bpm
  • Irregular - likely regularly irregular
  • Pattern of 2 sinus complexes followed by 2 ventricular complexes
  • Indeterminate
  • Sinus complexes
    • PR - Normal ( 160ms)
    • QRS - Prolonged (120ms)
    • QT - 400ms (QTc Bazette ~ 430 ms)
  • Ventricular complexes
    • QRS - Prolonged (180ms)
    • QT - 480ms 
  • ST Elevation V2-4 of sinus complexes discordant to QRS
  • Discordant ST & T wave changes of ventricular complexes
  • Notching in terminal portion of 1st ventricular complexes 
    • Best seen in lead II
    • Corresponds to atrial activity at a rate of 55 bpm
  • Regularly irregular atrial activity in pattern of 3 complexes then pause
  • Poor R wave progression

  • Sinus rhythm
  • Intraventricular conduction delay
  • Regular coupled ventricular ectopics
Without more clinical information it's hard to comment further on the likely causes for this ECG appearance but some potential culprits are:

  • Ischaemia
  • Electrolyte / acid base disturbance
  • Drugs
    • esp. digoxin
  • Environmental e.g. hypothermia

VAQ Corner

For those planning to sit the ACEM Fellowship, or any of our other interested readers.
 I don't know anything about the real case so I've made up the clinical details for this question.

A 76 yr old female presents to your ED following a collapse at home. 
She complains of feeling dizzy and lethargic for the last 2 days.
She has a history of IHD, CCF, and hypertension.
She is on multiple medications but can not recall them.
Observations: BP 85/45 RR 16 Sats 95% RA GCS 14 (M=6 V=5 E=3)

a) Describe & interpret the ECG (50%)
b) Outline your management (50%)

I won't directly be answering our VAQ corner questions on the blog, unless it's a 100% describe and interpret. These questions are designed to give people the oppurtunity to think about the ECG with some clinical context, especially when I don't have a real case to attach to, and also to provide a chance to do some VAQ practice. 
If people would like to submit some answers I will happily added them to our posts, just email them to me here.

References / Further Reading

Life in the Fast Lane

  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.